Levande.

correction orders using federal software. Please disregard the heading of the fourth column that states, "Provider's Plan of Correction." A plan of correction is not required. The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Kelly Thorson, Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 HHH An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 PRINTED: 06/18/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 33435 05/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2011 6TH LANE SE WALKER METHODIST LEVANDE LLC CAMBRIDGE, MN 55008 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 SL33435016-0 Minnesota Department of Health is documenting the State Correction Orders On May 5, 2025, through May 7, 2025, the using federal software. Tag numbers have survey at the above provider. At the time of the Statutes for Assisted Living Facilities. The survey, there were 68 residents; 53 receiving assigned tag number appears in the services under the Assisted Living with Dementia far-left column entitled "ID Prefix Tag." The Care license. As a result of the survey, the state Statute number and the licensee was found to be in compliance with the corresponding text of the state Statute out assisted living statutes 144G.08 through of compliance is listed in the "Summary 144G.95. Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the evaluators ' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 EZ2X11 If continuation sheet 1 of 1 Metro District Office 625 Robert St N, PO BOX 64975 St Paul, MN 55164 Phone: 651- 201- 4500 Food & Beverage Inspection Report Page: 1 Establishment Info License Info Inspection Info Walker Methodist Levande LLC License: HFID 33435 Report Number: F7963251007 2011 6th Lane SE Inspection Type: Full - Single Cambridge, MN 55008 Risk: Date: 5/6/2025 Time: 3:40: 53 PM Isanti County License: Duration: minutes Parcel: Expires on: Announced Inspection: No CFPM: Karen Niles Total Priority 1 Orders: 0 Phone: CFPM #: FM 44295; Exp: 2/7/2027 Total Priority 2 Orders: 0 Total Priority 3 Orders: 0 Delivery: Emailed No orders were issued for this inspection report. Food & Beverage General Comment MET WITH ESTABLISHMENT REPRESENTATIVES KAREN NILES AND JAKE COLLINS ALONG WITH MDH NURSE SURVEYOR SARABETH REMKER. DISCUSSED THE FOLLOWING- -EMPLOYEE ILLNESS POLICY AND LOG -REPORTABLE DISEASES -HIGHLY SUSCEPTIBLE POPULATION RESTRICTIONS -SANITIZERS AND WARE WASH SANITIZING TEMPERATURE REQUIREMENTS THIS IS A COMMERCIAL KITCHEN SPACE. NOTE: All new food equipment must meet the applicable standards of the American National Standards Institute (ANSI). Plans and specifications must be submitted for review and approval prior to new construction, remodeling or alterations. I acknowledge receipt of the Metro District Office inspection report number F7963251007 from 5/6/2025 Karen Niles Peggy Spadafore, MGR Public Health Sanitarian Supervisor 651- 201- 3979 peggy. spadafore@ state. mn. us Metro District Office 625 Robert St N, PO BOX 64975 St Paul, MN 55164 Temperature Observations/ Recordings Page: 1 Establishment Info Inspection Info Walker Methodist Levande LLC Report Number: F7963251007 Cambridge Inspection Type: Full County/ Group: Isanti County Date: 5/6/2025 Time: 3:40: 53 PM Food Temperature: Product/ Item/ Unit: CUT LETTUCE ; Temperature Process: Location: Prep Rail at 38 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: CKD EGGS ; Temperature Process: Location: Prep Rail at 37 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: MASHED POTATOES ; Temperature Process: Location: Hot Line at 177 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: STUFFED PEPPERS ; Temperature Process: Location: Hot Line at 198 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: MILK; Temperature Process: Location: Walk-in Cooler at 37 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: COLESLAW ; Temperature Process: Location: Walk-in Cooler at 36 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: MILK; Temperature Process: Location: BEVERAGE AREA at 40 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: MILK; Temperature Process: Location: MEMORY CARE at 40 Degrees F. Comment: Violation Issued? : No Metro District Office 625 Robert St N, PO BOX 64975 St Paul, MN 55164 Sanitizer Observations/ Recordings Page: 1 Establishment Info Inspection Info Walker Methodist Levande LLC Report Number: F7963251007 Cambridge Inspection Type: Full County/ Group: Isanti County Date: 5/6/2025 Time: 3:40: 53 PM Sanitizing Chemical: Product: Quaternary Ammonia ; Sanitizing Process: Wiping Cloth Bucket Location: Equal To 200 PPM Comment: Violation Issued? : No Sanitizing Chemical: Product: Quaternary Ammonia ; Sanitizing Process: Dispenser Location: Equal To 400 PPM Comment: Violation Issued? : No Sanitizing Equipment: Product: Hot Water ; Sanitizing Process: Location: Dishwashing Area Equal To 167 Degrees F. Comment: Violation Issued? : No Minnesota (MDH) Version Food Establishment Inspection Report Page_ 1_ _ of _1__ EH Manager; RPT: F7963251007 Metro District Office 0 No. of Risk Factor/ Intervention/ Violations Date: 5/6/2025 625 Robert St N, PO BOX 64975 No. of Repeat Risk Factor/ Intervention/ Violations Time: 3:40:53 PM St Paul, MN 55164 Score (optional) Dur: min Establishment: Address: City/State: Zip: Phone: Walker Methodist Levande LLC 2011 6th Lane SE Cambridge, MN 55008 License/ Permit #: Permit Holder: Purpose of Inspection: Est.

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident the facility delayed administration of anxiety and pain medications. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. While there was some delay obtaining the resident’s medications upon admission, this delay was caused by confusion in the orders between the hospice provider and the pharmacy. The facility took appropriate steps to address the miscommunication. This medication was to be given as needed (prn). The Pharmacist caught the mistake and contacted the facility to clarify the order. The facility then contacted the hospice RN for the correct order which caused a 36-hour delay in the correct medication being sent to the facility and given to the resident. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted family members and the hospice agency. The investigation included review of medical records, facility records, email communications plus policies and procedures. Also, the investigator observed interactions between staff, residents, and visitors. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s dementia, and history of multiple TIA’s (transient ischemic attack which is a brief blockage of blood flow to the brain). The resident’s service plan included assistance with ambulation, meals, dressing, grooming, medication, and behavior redirection. The resident’s assessment indicated he had wandering behaviors and could get agitated at times. The resident was on hospice prior to admission to the facility and continued hospice services at the facility due to end stage dementia. Upon admission to the facility, the facility had difficulty obtaining his medications including as needed medications. During the admission process the facility nurse and the hospice nurse communicated to understand the roles and responsibilities for the facility and the hospice organization. It was determined the hospice agency would be manage the residents’ medications, which included ordering medications, and changes such as starting or stopping medications. The resident’s medical record indicated the hospice nurse placed orders for the resident’s medications including lorazepam (an anti-anxiety mediation) to be given as needed. However, when the pharmacy received the orders, it was late in the day and most of the medications were sent to the facility early the next day. Unfortunately, the pharmacy required clarification of the lorazepam orders and could not be sent immediately. The pharmacy contacted the facility nurse who subsequently contacted the hospice nurse who provided clarification so the order could be filled by the pharmacy. A review of electronic communication between the between the facility and the hospice provider indicated both took action to address the resident’s medications. During an interview, the facility nurse stated the resident did have some wandering behaviors and did not sleep at night during the first week or so, but this was the resident’s baseline. The facility nurse also stated although the resident did not come to the dining room during this time, he was offered and refused, the staff did bring him food in his room. During an interview, the hospice nurse stated people with dementia often exhibit the types of behaviors the resident did when entering a new and unfamiliar environment as he did upon admission. The hospice nurse stated resident was calm and did not seem agitated when she saw him in-person at the facility so she would not have given the resident an as-needed medication on those occasions. During an interview, the family member had concerns about pain medication not given in a timely manner. A review of email communication regarding the resident’s pain medications indicated hospice addressed updating the resident’s pain medications including morphine and fentanyl patch. The resident’s medication administration record indicated the facility began administering these medications the same day as the email. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 Neglect means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No, passed away Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable the Action taken by facility: The facility appropriate action while coordinating cares with the hospice provider. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 08/08/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 33435 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2011 6TH LANE SE WALKER METHODIST LEVANDE LLC CAMBRIDGE, MN 55008 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On June 25, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL334351361C/#HL334352320M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Z88G11 If continuation sheet 1 of 1

CORRECTION ORDERS The enclosed State Form documents the state correction orders. The MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines and enforcement actions based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Walker Methodist Levande LLC August 11, 2023 Page 2 CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by the MDH within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. Please email reconsideration requests to: Health.HRD.Appeals@state.mn.us. Please attach this letter as part of your reconsideration request. Please clearly indicate which tag(s) you are contesting and submit information supporting your position(s). Please address your cover letter for reconsideration requests to: Reconsideration Unit 85 East Seventh Place St. Paul, MN 55164-0970 You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Kelly Thorson, Supervisor State Evaluation Team Email: kelly.thorson@state.mn.us Telephone: 320-223-7336 Fax: 6 51-281-9796 JMD PRINTED: 08/11/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 33435 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2011 6TH LANE SE WALKER METHODIST LEVANDE LLC CAMBRIDGE, MN 55008 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Licensing ASSISTED LIVING PROVIDER LICENSING Correction Orders using federal software. CORRECTION ORDER(S) Tag numbers have been assigned to Minnesota State Statutes for Assisted In accordance with Minnesota Statutes, section Living License Providers. The assigned 144G.08 to 144G.95, these correction orders are tag number appears in the far left column issued pursuant to a survey. entitled "ID Prefix Tag." The state Statute number and the corresponding text of the Determination of whether violations are corrected state Statute out of compliance is listed in requires compliance with all requirements the "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL33435015 PLEASE DISREGARD THE HEADING OF On July 17, 2023, through July 19, 2023, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION." THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were 70 active residents; 49 WILL APPEAR ON EACH PAGE. receiving services under the Assisted Living with Dementia Care license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G.31 subd. 1, 2, and 3. 0 480 144G.41 Subd 1 (13) (i) (B) Minimum 0 480 SS=F requirements (13) offer to provide or make available at least the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 HI5Z11 If continuation sheet 1 of 14 PRINTED: 08/11/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 33435 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2011 6TH LANE SE WALKER METHODIST LEVANDE LLC CAMBRIDGE, MN 55008 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 480 Continued From page 1 0 480 following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the residents). The findings include: Please refer to the included document titled, Food and Beverage Establishment Inspection Report dated July 19, 2023, for the specific Minnesota Food Code deficiencies. TIME PERIOD FOR CORRECTION: Twenty-one (21) days 0 800 144G.45 Subd. 2 (a) (4) Fire protection and 0 800 SS=F physical environment (4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the STATE FORM 6899 HI5Z11 If continuation sheet 2 of 14 PRINTED: 08/11/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 33435 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2011 6TH LANE SE WALKER METHODIST LEVANDE LLC CAMBRIDGE, MN 55008 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 800 Continued From page 2 0 800 residents in accordance with a maintenance and repair program. This MN Requirement is not met as evidenced by: Based on observation and interview, the licensee failed to maintain the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents. This deficient condition had the potential to affect all staff, residents, and visitors.